Can Health Plans Explain Why They Aren't Re-Empowering Primary Care?

Brian Klepper and David Kibbe offer a post today on the issue of primary care and the role they believe health plans should be taking to encourage greater involvement with PCPs. They ask why health plans are not being more proactive in partnering with PCPs to control costs.Can Health Plans Explain Why They Aren't Re-Empowering Primary Care?By Brian Klepper & David KibbeSometimes a whisper is more

Health Wonk Review is UP!

David Harlow hosts this week's edition of Health Wonk Review over at his, "HealthBlawg."It is a very comprehensive sample of some of the best recent posts from the world of health blogs.

The McCain Health Plan's Good Idea for Health Care Reform--Likely Going Down With the Candidate

John McCain would reform the American health care system by providing big tax incentives for it to transition from being employer-based to one built on a system of individual responsibility. He would do this by eliminating the longtime personal tax exemption on employer-provided health insurance and replacing it with a $2,500 individual, and $5,000 family, tax credit for those who have health

Coventry Health Care Stock Down 48%--"Sort of" No Surprise

Readers of this blog will not be surprised to see Coventry Health Care's stock down 48% this afternoon after its earnings call this morning.That is a 77% drop from their 52-week high.Last July I commented on their earnings call where senior management used the precise financial term "sort of" 63 times to explain their then earnings and operations situation: Required Reading for Health Care

What Impact Do Medical Costs Have on Home Mortgage Foreclosures?

That is the subject of a recent paper by Christopher T. Robertson, Richard Egelhof, & Michael Hoke.The authors studied homeowners going through foreclosure in four states and found a big impact on their being able to stay in their house because of the health care cost issues these families had to deal with.Here is an excerpt from their work:"This preliminary study reveals that the standard

Underwriting Tip (Individual & Family California)

I wanted to address an issue with regard to underwriting for individual and family health insurance plans in California. A little tip to help you determine what plan rates to target and whether or not you would be considered for coverage.

Ignoring for a moment any health conditions that are ongoing (these are dealt with separately), we need to talk about your Rx and how it affects underwriting.

Here is a simple formula for you:

Take you monthly retail brand Rx costs and multiply them by four.

This is the minimum premium amount that you would need to target before a carrier would even consider underwriting your case.

So, let's say you have the following brand drug costs per month (you can go to drugstore dot com and get average retail pricing):

1 brand drug at $131.00
1 brand drug at $97.00
Total brand = $227.00
Minimum target premium = $908.00 (4x brand drug cost)

That means that the approximate minimum premium rate that a carrier might consider to underwrite would be over $900 per month. If you choose a $120 per month plan, since the maximum rate increase on PPO plans (there is no rate up on California HMO plans) is 2x standard premium, you would be declined for coverage right off of the application since the max rate for that plan would be $240.00 at the top rate-up.

If you can't find any PPO plan in the carrier's options that costs at least 1/2 of $908 ($454), then there is no point in even applying for coverage.

Remember this is a tip regarding Rx usage. And be aware that carriers check through services like Intelliscripts to verify every fill you've had for any Rx over the last few years. If there are further health conditions beyond the Rx, even if you can find a plan that meets this basic rule, you might (and probably will) still be declined for coverage.

Underwriting and Declines (Individual & Family)

I wanted to talk a bit about something that has come up quite a bit recently concerning declined coverage and health insurance underwriting in California.

I always maintian that, with the exception of MRMIP enrollments which require a decline, generating a decline unnecessarily is never a good idea. Many people have called me in the last few months who have been advised by another agent to submit an application for health insurance even though the health history appears to be problematic. This is never a good idea and is, truthfully, not necessary to determine within a reasonable degree the outcome of the underwriting.

We, as agents, are able to call into the carrier's underwriting departments and, anonymously request and underwriting "review" for any prospective applicant. In most cases, given a reasonably accurate history, that underwriter can tell us whether or not the application would be declined for coverage. Also, agents have an underwriting guideline for each carrier they represent and often the answer can be found there without the need to even call an underwriter. No need to expose you to a decline that will be on your record for 10 years.

Now, some will say "yes, but each carrier does its own underwriting without regard to another carrier's decision" and this is absolutely true. However, if a person is declined for coverage, for the next 5-10 years, depending on the question in an application, that person MUST indicate that he/she was declined for coverage. This will be an instant red flag to the new underwriter who will likely take a very thorough approach to the applicant. This question will appear on both individual and employer-sponsored group applications. It's a stigma that should be avoided whenever possible. Kind of like a ding on your credit rating.

Let your agent do the work up front, look at all of your options, and make your decision based on the most accurate probability, not just flinging an application into underwriting and hoping for the best.

Welcome!

I would like to welcome you to my California Health Insurance weblog. Unlike other insurance blogs, which are sales-oriented, the intention of this blog is to provide the reader with pertinent and important information about health plans, benefit provisions, peculiarities, underwriting, and many other topics not frequently disclosed to the public.

If you visit my web site (www.davefluker.com), you will find that I am a non-traditionalist as an independent agent. I work primarily with individuals, families, seniors and very small businesses (mostly spousal) who have difficulty in obtaining quality health insurance and may be unaware of programs available or protections under the California law.

I hope that you will find this weblog and my web site of value and I welcome feedback and comments.

Dave

Demystifying U.S. Health Care Spending--Some Surprising Information

Paul Ginsburg, of the Center for Studying Health System Change, has just authored a new report, "High and Rising Health Care Costs: Demystifying U.S. Health Care Spending." The report is part of the Robert Wood Johnson Foundation's Synthesis Project.This paper reviews existing literature in search of a more clear understanding of U.S. health care costs, the drivers, and the trends.It is an

HIGH AND RISING COSTS: DEMYSTIFYING U.S. HEALTH CARE SPENDING

I have seen an advance copy of this very comprehensive report on the growth in health care spending. If you are in DC next week, I highly recommend this event to you:HIGH AND RISING COSTS: DEMYSTIFYING U.S. HEALTH CARE SPENDINGNew Report Synthesizes the Literature on the Growth of Health Care SpendingConcern about high and rising health care costs in the United States has increased sharply in

Time to Get Real--On the Economy and Health Care Reform

I just got a call from a reporter at one of the major news organizations to talk about the chances for health care reform.We both commented on the almost surreal environment we are all in. I'm not sure if my friends and neighbors are in denial or just numbed by the recent cascade of events in the financial world. Up on the Hill and in the presidential campaigns it's business as usual when it

The Big Elephant in the Room During the Presidential Debate

Last night Tom Brokaw asked Barack Obama and John McCain to prioritize health care, Medicare/Social Security, and energy. Neither of them backed down from their promises to deal with all of them.When Jim Lehrer tried to challenge them at the last debate on their ability to do all of the expensive things they want to do he got pretty much the same answer.About the only two people in America that